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Bridging the Chasm Between Health and the Environment: Science and Policy Context*

A CONGRESSIONAL PERSPECTIVE

The Honorable Hillary Rodham Clinton

The Gulf War syndrome was one of my first encounters with the intersection between environmental exposures and health. Many Gulf War veterans were increasingly concerned about the state of their health and that of their families, and I received many letters expressing these concerns. There were numerous explanations for their symptoms ranging from immunization—vaccinations that were given en masse to our men and women in uniform—to the oil burning fires, the abundant use of insecticides, and so forth. At the end of the inquiry, I believe scientists concluded that the symptoms were caused by a combination of genetic susceptibilities to an environmental exposure among a subset of our military population.

In parallel to the Gulf War experience, there have been a number of acute health observations in recent years that became the driving force behind the proposed environmental health tracking act, including the unusually high numbers of childhood leukemia in Fallon, Nevada (Nevada State Health Division, 2002), the higher-than-national average of breast cancer in Long Island (Kulldorff et al., 1997), and the World Trade Center cough among rescue workers of September 11. In addition, we are seeing increases in a number of other diseases. Childhood asthma rates have increased 20 percent in the past 10 years, while endocrine and metabolic disorders such as diabetes and neurological disorders such as Parkinson’s also are on the rise. The disease clusters and increases in

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This chapter was prepared by staff from the transcript of the meeting. The discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics.



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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary 1 Bridging the Chasm Between Health and the Environment: Science and Policy Context* A CONGRESSIONAL PERSPECTIVE The Honorable Hillary Rodham Clinton The Gulf War syndrome was one of my first encounters with the intersection between environmental exposures and health. Many Gulf War veterans were increasingly concerned about the state of their health and that of their families, and I received many letters expressing these concerns. There were numerous explanations for their symptoms ranging from immunization—vaccinations that were given en masse to our men and women in uniform—to the oil burning fires, the abundant use of insecticides, and so forth. At the end of the inquiry, I believe scientists concluded that the symptoms were caused by a combination of genetic susceptibilities to an environmental exposure among a subset of our military population. In parallel to the Gulf War experience, there have been a number of acute health observations in recent years that became the driving force behind the proposed environmental health tracking act, including the unusually high numbers of childhood leukemia in Fallon, Nevada (Nevada State Health Division, 2002), the higher-than-national average of breast cancer in Long Island (Kulldorff et al., 1997), and the World Trade Center cough among rescue workers of September 11. In addition, we are seeing increases in a number of other diseases. Childhood asthma rates have increased 20 percent in the past 10 years, while endocrine and metabolic disorders such as diabetes and neurological disorders such as Parkinson’s also are on the rise. The disease clusters and increases in *   This chapter was prepared by staff from the transcript of the meeting. The discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary their rates have led many people to look at the role of the environment in determining health status. What we know now is that too often there is little information on exposure with which to understand causal effects between the complexity of our environment and the reported increase of various diseases. In Fallon, Nevada, the drinking water contains 100 parts per billion of arsenic—10 times the recommended level proposed by the previous administration. Further, because of agricultural activity, pesticides are on the ground as well as aerially applied. At the Congressional hearing, it became evident that in order to understand these linkages, we will require more information about environmental factors, their effects on the population, and resulting health outcomes. Similarly in Long Island, researchers do not have the answer as to why breast cancer is higher than the national average. One can look at what is unique to the environment. Long Island was an agricultural center and still produces more agricultural dollars than any place in New York. It also was the center of war-time industry, resulting in heavy metal and chemical usage. Further, an aquifer that runs the length of the island has been contaminated for decades by pesticide runoff and, more recently, by fuel additives, such as methyl tertiary-butyl ether (MTBE). These are a few of the questions that members of the public have in their minds about the possible causal effects of breast cancer in this region. What we know now is that too often there is little information on exposure with which to understand causal effects between the complexity of our environment and the reported increase or various diseases. -Hon. Hillary Clinton What we must do is establish a nationwide network to track chronic diseases, environmental exposures, and other risk factors. This will allow researchers and health officials to identify the causes of chronic diseases and, ultimately, develop strategies to prevent these diseases in the future. Through investigation of incidences in Fallon and Long Island, we discovered that most states are well equipped to track infectious diseases but are not able to track chronic diseases. We will have to provide states with environmental health tracking grants so that they are able to develop the infrastructure they need to participate in the nationwide network. As part of the Nationwide Health Tracking Network Act (U.S. Senate, 2002), we will have to create a national environmental health rapid-response service to develop and implement strategies for coordinated rapid responses to public health and environmental concerns. There will

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary be a need to expand our environmental health center structures through the establishment and operation of at least five regional biomonitoring laboratories, five environmental health centers of excellence, and the John H.Chafee environmental health scholarship program. Finally, the Act calls for a national environmental health report that will provide the public with the findings of the tracking network and the information it needs to ensure environmental health within its communities. Discussions of the nationwide tracking network are timely. Senators who serve on the Environmental Committee know that we face a broad range of pressing environmental problems, and there is no substitute for vigorous debate on how to address them. For this reason, we need the scientific research community to lead the charge in establishing the tracking system to ensure that the data are nonpartisan and accurate. This will be necessary to help inform the public’s decision-making process. At some level, people will have to recognize that we are all responsible for our health. Each of us can help make ourselves healthier by staying away from bad habits and behavior and by making our environment as user-friendly as possible. However, we have to recognize that there are many issues related to health and the environment over which no individual has any control. If there is any area that needs society as a whole to act, it is the intersection of health and the environment. We need the scientific research community to lead the charge in establishing the tracking system to ensure that the data are nonpartisan and accurate. -Hon. Hillary Clinton A VIEW FROM THE ENVIRONMENTAL PROTECTION AGENCY Paul Gilman At the Environmental Protection Agency (EPA) we work at the bottom of the chasm between health and environment. It is part of the mission of the EPA to create links between environmental stressors and ecosystem or human health outcomes when a sturdy and formal bridge across the chasm has yet to be built. This is not to say that we haven’t made a number of strides in building these linkages. In fact, research related to particulate matter and asthma is one of many examples of how we are trying to establish these links and use that information to direct

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary future research. The Office of Environmental Information and the Office of Research and Development are leading an agency-wide “environmental indicators initiative” that will help the EPA understand where we are and where we must proceed in order to make sound, strategic decisions. Constructing these links requires solid building materials, rigorous tools, and a commitment to the task. At the EPA, our building materials are our vast physical and human infrastructure, our prior experiences in monitoring, and our partnerships with traditionally autonomous environmental and health organizations, including the Centers for Disease Control and Prevention (CDC) and the National Institute for Environmental Health Science (NIEHS). Our toolbox is filled with a variety of quantitative methodologies. By using these tools in conjunction with our building materials, I believe that we can make great progress in forging the links between environmental stressors and health outcomes. We have learned a great deal from previous attempts to monitor the health of ecosystems, and these lessons are useful not only to the EPA, but also to other groups that monitor ecosystem or human health. However, like the proverbial man who misplaces his keys in his house but searches for them under a brightly lit lamppost because the area is easy to see, we at the EPA may become overwhelmed by the large amounts of information available to us and overlook connections and causal relationships between environment and health outcomes because they are not easily accessible. In the early 1990s, the National Research Council (NRC, 1995) highlighted the disjunction between EPA’s data on environmental indicators and ecosystem health outcomes. To address this issue, the EPA, in conjunction with the NRC, developed the Environmental Monitoring and Assessment Program (EMAP). The goal of EMAP is to “develop the tools necessary to monitor and assess the status and trends of national ecological resources” (USEPA, 2002). As we developed EMAP, I believe we overcame some hurdles in identifying appropriate indicators for truly understanding the health of coastal ecosystems. Strategic programs such as EMAP provide a template for integrating monitoring data from many spatial and temporal scales and are critical for connecting environmental characteristics with human health outcomes. Programs such as EMAP can help bridge the environment-health chasm only if they use appropriate tools and rigorous, quantitative, and accessible methodologies. Advances in technologies and tools, such as the use of biomarkers, risk assessment, and exposure assessment and

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary modeling, have increased our understanding of how environmental exposures, including exposures of susceptible populations, translate into health effects. Biomarkers measure a biological response to an environmental chemical. Biomarkers of exposure, effect, and susceptibility are important measures of toxicity that help quantify early responses to exposures and identify the most susceptible populations at risk. Risk assessment, including cumulative risk assessment, is a relatively accurate tool to characterize the chasm, effectively narrowing the divide between environmental characteristics and health outcomes. However, I do not believe that risk assessment is as accessible to decision makers as it should be. Exposure research is another important tool for developing and understanding the links between our environment and our health. A challenge that we face in exposure research is to probe well beyond physical exposure routes to understand the pathways within our bodies as well. EPA scientists have begun to address the notion of compound mixtures instead of “simple” single compounds. Aggregating exposure data helps define the various pathways where a particular compound is acting within the complex tapestry of environment and health interactions. Understanding the intricate interplay between exposure measurements and health outcomes frequently requires a large degree of modeling. It is often unrealistic to quantify exposure at maximum levels. Although quantifying exposure at low doses leads to reasonable extrapolation, the interplay between modeling and the actual measurement is ultimately what enables the extrapolation of data that are informative to policy makers. Because time constraints compel us to span the environmental health chasm before the bridge is built, the use of models to make accurate extrapolations is a primary tool of the EPA. Integrating tools, as well as data, from traditionally autonomous environmental and health organizations through partnership building is an important part of our construction strategy. For example, the EPA recently partnered with the CDC in a National Health and Nutrition Examination Survey (NHANES) study of blood lead levels. Although the CDC primarily collects human health data, scientists have become increasingly interested in environmental stressors. While the CDC continues to monitor blood chemical levels, the EPA will work with it to address research questions regarding route of exposure. I believe this collaborative research project is a very productive interaction for fostering environment and health bridge building and for co-launching the Na-

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary tional Children’s Environmental Health Study, in which both health outcomes and environmental stressors will be tracked. As we begin to establish a national monitoring system, we have to keep in mind a number of issues. The protocol for linking environmental and health research programs and policy initiatives must be multifaceted. We must continue to fill our toolbox with additional research methodologies that help us to understand better the complex interaction between environmental stressors, ecosystem health, and human health outcomes. Exposure and epidemiologic studies must be conducted to tease out the details of causality. Laboratory-based studies have to be conducted concurrently to illustrate the distinctions between very low dose events and extrapolated health outcomes. Modeling studies link exposure models to pharmacokinetic models and provide informative extrapolations for decision makers. By drawing on previous experience and forming integrated partnerships, we can proceed more efficiently in constructing this bridge. Throughout these processes, scientists and policy makers must remain cognizant of the many physiological pathways by which susceptible and nonsusceptible populations may be affected by the complex mix of chemicals in our environment. A VIEW FROM THE DEPARTMENT OF HEALTH AND HUMAN SERVICES Eve Slater During the last century, advances in the field of public health, particularly in the treatment of infectious diseases, contributed greatly to improving the health of the people of the United States and other countries. The effect of diseases such as smallpox and malaria has greatly diminished as a result of combined scientific and public health efforts. These advances provide encouragement for the challenges that we face in improving public health, including those threats that are environmentally linked. Through the passage of the Clean Air Act, the Safe Drinking Water Act, and other legislation, we have begun to make good progress in several areas of environmental health in this country. Further, behavioral changes are beginning to have an influence on our environmental exposures. For example, the CDC reported a 75 percent reduction in exposure

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary to environmental tobacco smoke from 1980 to 1999, which is a true environmental health accomplishment (CDC, 2001). While this is promising, many environmentally related diseases, including cancer and asthma, still pose great challenges. Cancer and asthma illustrate the complexity of gene and environment interactions, where it is clear that not everyone exposed to an environmental toxicant will contract a disease. For example, environmental tobacco smoke has been clearly linked with cancer, yet only about 20 percent of smokers develop cancer, suggesting that some individuals have a predisposition to developing cancer. Scientists are beginning to understand the genetic predisposition to environmental diseases by studying the altered expression of genes and enzymatic activity as a result of environmental exposure. One such study examined the link between the NAT2 gene for acetyltransferase (an enzymes that metabolizes nicotine) and bladder cancer in nonsmokers and smokers. Results of the study revealed a twofold increase in the risk of developing bladder cancer in subjects who were slow acetylators—that is slow in breaking down nicotine. Studies of this type can potentially provide an effective tool for proactively addressing environmentally related health outcomes. Scientists are beginning to understand the genetic predisposition to environmental diseases by studying the altered expression of genes and enzymatic activity as a result of environmental exposure. -Eve Slater Similarly, a wealth of evidence suggests that asthma attacks are triggered by local environmental factors ranging from indoor irritants, such as mold and tobacco smoke, to outdoor air pollutants, such as ozone. Preventing and treating these complicated interactions requires a multifactorial and community-based approach to asthma management. For example, at health centers in Detroit, Michigan, families are linked to local and state public health officials through a complex yet realistic “people chain.” The families are connected through their neighborhoods to school nurses trained in asthma detection. The nurses, in turn, are connected to state and local public health officials who help them understand asthma symptoms, treatment, and proper care. Another Detroit group has employed community residents to measure air particulate matter in two locales, thus allowing community members themselves to conduct the study to determine the source of environmental exposures. Presumably, their findings will be translated into a health benefit. Finally, in a study performed in conjunction with the Los Angeles School District, re-

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary searchers found a 15 percent decrease in emergency room visits and a 30 percent decrease in hospitalizations for middle-school children with asthma one year after establishing a multidisciplinary team of health care professionals, service workers, and school nurses, who worked closely with parents and children to develop asthma management plans. These examples illustrate the benefit of developing community-based approaches for tackling the prevention of environmentally triggered diseases. One problem in linking environmental and health information has been the lack of sophisticated measurement tools in the environmental sciences. However, I believe that environmental science is coming of age. Scientists now have the capacity to translate information about the human genome into environmental observations and subsequently into scientific fact. The science of proteomics will greatly help us decipher the interaction between our genes and our environment as a result of very elegant informatic and biochemical tools that allow us to translate the effect of environmental factors on protein translation. These new techniques will permit a great leap forward in environmental health. An enormous amount of environmental data has been collected, and we must continue to develop tools to use this information appropriately. Environmental science is coming of age. Scientists now have the capacity to translate information about the human genome into environmental observations and subsequently into scientific fact. -Eve Slater Many challenges still lie ahead as we work to bridge the chasm between environment and health. We must track environmental hazards and diseases in ways that provide accurate information and both inform and empower health policy makers, state and local workers, community participants, and patients. We must strive to develop community-based decisions and eliminate health disparities. We need sound science and working partnerships to meet specific goals—such as quickly controlling the asthma epidemic and eliminating lead poisoning by 2010—and to influence chronic diseases in a more general way. In conclusion, the strong link between environmental factors and health effects indicates that public health leaders must be included whenever environmental issues are discussed.